WELL CHILD/PEDIATRIC AND ADOLESCENT



WELL CHILD/EPSDT

PEDIATRIC AND ADOLESCENT

PREVENTIVE HEALTH GUIDELINES

Purpose/Policy

The purpose of the Well Child/Pediatric and Adolescent Preventive Health Care program is to provide Comprehensive Health and History screening and assessment of the physical, mental, and social well being of children birth through 20 years of age. If a patient is currently receiving preventive healthcare from another provider, the patient should be referred back to that provider. If a patient is not currently receiving preventive health care from another provider, preventive health care should be offered/provided. The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents is the recommendation of The American Academy of Pediatrics.

A registered Public Health Nurse or nurse practitioner must complete the state approved Pediatric Assessment/Well Child Certification program prior to performing pediatric screening services in a health department setting. APRN (Advance Practitioner Registered Nurse who are certified in pediatrics are exempt. All other APRN’s must complete the course prior to performing pediatric services. Registered nurses and APRN’s that participate in the Kids Smile: Fluoride Varnish Program for oral screening or fluoride application is required to complete the training for the Kids Smile Fluoride Varnish Program.

Patients with conditions suspected of falling outside the normal screening parameters described in the following section should be re-screened when appropriate or referred to local physicians for further diagnosis and treatment of their acute or chronic conditions. LHDs’ staff physicians, family practice or pediatric nurse practitioners may diagnose and treat children as appropriate. When no other care is available, children with chronic medical conditions should be coordinated with local physicians or the Kentucky University Clinics.

Children with suspected genetics problems should be referred to one of the Genetics Clinics (refer to the Genetics Section). Children with suspected Developmental Delay should be referred for developmental evaluation and screening (refer to the KEIS Section).

References:

American Academy of Pediatrics Standards of Care, Pediatrics, August 2, 1995, volume 96, number 2.

American Academy of Pediatrics, Committee on Infectious Diseases, Pediatrics, 1996, volume 97, number 2.

American Academy of Pediatrics, Cholesterol in Childhood, Pediatrics, volume 101, number 1, 1998.

American College of Obstetrics and Gynecology, Committee on Gynecologic Practice, March 1995, number 152.

Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Third Edition, National Center for Education Maternal and Child Health, 2008, Arlington, VA.

WELL CHILD/PEDIATRIC PREVENTIVE HEALTH CARE

(Birth through 15 months)

|AGE |0–1 |

| |M |

|Initial/Interval History |X |

|PHYSICAL EXAM¹ (comprehensive) | |

|HEIGHT/WEIGHT |X |

|VISION |S |

|METABOLIC SCREENING7 |X |

|FLUORIDE8 |R |

|Initial/Interval History |X |

|PHYSICAL EXAM¹ (comprehensive) |X |

|HEIGHT/WEIGHT |X |

|VISION |S |

|SICKLE CELL DISEASE6 | |

|FLUORIDE7 |R |

|Initial/Interval History |

|HEIGHT/WEIGHT |

|VISION |

|SICKLE CELL DISEASE10 |

|FLUORIDE11 |R |R |

|CHILD ABUSE/ NEGLECT |Family History of Domestic Violence |Provide/refer for parenting classes |

|(Emotional, Physical, Sexual, or |Family History of Substance Abuse |Basic nutritional counseling |

|Neglect) |Inappropriate Parent/Child Interactions: |Medical nutrition therapy for FTT |

| |Consistent Hunger |Referrals for mental health/social services |

| |Failure to Thrive (FTT) |Refer for medical evaluation as indicated |

| |Abandonment |Report suspected abuse/neglect to Department for |

| |Inappropriate Discipline |Community-Based Services KRS 620.030 |

| |Unusual/Inappropriate Child Behaviors: | |

| |Conduct Disorders | |

| |Habit Disorders | |

| |Neurotic Disorders | |

| |Withdrawn | |

| |Poor Peer Relationship | |

| |Psychosomatic Complaints | |

| |Sexual Acting Out | |

| |Physical Indicators: | |

| |Unkempt and/or Unclean | |

| |Malnourishment | |

| |Unexplained Bruises, Burns, Fractures, Abrasions/Lacerations, | |

| |Bite Marks, or Scars on Body (anywhere) | |

| |Vaginal Lacerations (External/Internal) | |

| |Rectal Excoriations | |

| |Evidence of having had sex under age 16 | |

|INFECTIONS |Unsanitary Living Environment |Anticipatory guidance hand washing, personal |

| |Inadequate Parenting Skills |hygiene, s/s infection, dangers tobacco |

| |Tobacco Smoke |Provide/refer for parenting classes |

| |Physical Indicators: |Basic nutrition counseling |

| |Prematurity (birth–12 months) |Screen for WIC services 2 years |

| |times a day |Apply fluoride varnish at the eruption of the |

| |Red Swollen Gums |first tooth and repeat every 6 months. |

| |Leukoplakia | |

| |Gingivitis | |

| |Oral Cyst/Lesions | |

| |Pain, halitosis, loose teeth | |

| |Loose Teeth | |

| |Malignment | |

|HEARING LOSS |Family History |Anticipatory guidance on S/S of infections, |

| |Recurring Otitis Media |antibiotic therapy, feeding position for infants, |

| |Structural Defects or Injuries: |follow-up ear exam |

| |Abnormality External Ear Structure |Refer for medical evaluation acute or chronic |

| |Abnormality Internal Ear Structure |conditions |

| |Physical Indicators: |Refer for parents for genetic services as |

| |Discharge from Ears |indicated |

| |Enlarged Tender Lymph Nodes |First Steps (birth – 3 years) with confirmed |

| |No Intelligible Speech by 2 years |hearing loss diagnosis |

| |Failure to Localize Sound |Refer to CCSHCN |

| |Imbedded Foreign Bodies | |

| |Impacted Cerumen | |

| |Furunculosis | |

| |Mycotic (fungus) Infection | |

|OCULAR PROBLEMS |Confirmed Blindness |Anticipatory guidance S/S eye problems/infections |

| |Physical Indicators: (birth through 20 years) |Age appropriate eye screening |

| |Eyes rubbed excessively, inflamed, water, red-rimmed, and/or |Refer for medical evaluation acute or chronic |

| |encrusted |conditions |

| |Eyelids Swollen |Refer for Ophthalmology evaluation |

| |Injury |Refer for genetic services as indicated |

| |Eyes Itch, Burn, or Scratch |Refer CCSHCN |

| |Dizziness, Headaches, or Nausea |Refer to First Steps (birth to 3 years) |

| |Squints Eyelids or Frowns | |

| |Tilts Head or Thrust Head Forward | |

| |Holds Objects Close | |

| |Covers or shuts one eye | |

| |Recurring Styes | |

| |Inflammation of lacrimal sac | |

| |Prolonged setting sun sign | |

| |Asymmetry in Corneal Reflex | |

| |Absent Pupillary Light Reflex | |

| |Marked Strabismus | |

PEDIATRIC PREVENTIVE HEALTH GUIDELINES

(continued)

|CONDITION |RISK FACTORS AND SYMPTOMS |MANAGEMENT/COUNSELING |

|DIABETES |Type 1 (formerly called Insulin Dependent Diabetes Mellitus or |Anticipatory guidance regarding food purchasing, |

| |IDDM) |food preparation, and nutrition |

| |RISK FACTORS |Education and counseling regarding blood glucose |

| |Family History |testing only if indicated |

| |SYMPTOMS |Refer for medical evaluation for acute and chronic|

| |The Three POLYS (Cardinal Symptom of Diabetes) |abnormal blood glucose results |

| |Polyphagia |Refer to dentist for oral problems |

| |Polyuria | |

| |Polydipsia | |

| |Weight Loss | |

| |Nausea, vomiting, abdominal pain | |

| |Child may start bed-wetting | |

| |Irritability | |

| |Short attention span | |

| |Appears overly tired | |

| |Dry skin | |

| |Blurred vision | |

| |Sores that are slow to heal | |

| |Flushed skin | |

| |Headache | |

| |Candida Vaginitis | |

| |May Exhibit: | |

| |Hyperglycemia | |

| |Elevated blood glucose | |

| |Glycosuria | |

| |Diabetic Ketosis | |

| |Ketones as well as glucose in the urine | |

| |No noticeable dehydration | |

| |Diabetic Ketoacidosis | |

| |Dehydration | |

| |Electrolyte imbalance | |

| |Loose teeth, bleeding gums, abscess | |

| |Type 2 (formerly called Non-Insulin Dependent Diabetes Mellitus | |

| |or NIDDM) | |

| |RISK FACTORS | |

| |According to CDC, BMI >85th percentile to 95th percentile is | |

| |considered overweight. See MCH 1–4 (Growth Charts for BMI). | |

| |Family history | |

| |Race/ethnicity | |

| |Signs of insulin resistance or conditions associated with | |

| |insulin resistance (acanthosis nigricans, hypertension, | |

| |dyslipidemia, or PCOS) | |

| |Periodontal Disease | |

| |SYMPTOMS | |

| |Weight gain | |

| |Fatigue | |

| |Frequent infections | |

| |There may be no symptoms | |

| |Clinical judgment should be used to test for diabetes in high | |

| |risk patients who do not meet the criteria. | |

|CONDITION |RISK FACTORS |MANAGEMENT/COUNSELING |

|CANCER |Family History |Anticipatory guidance on warning signs, exposure |

|Leukemia |Smoking |to ultraviolet rays |

|Lymphoma |Sexual Intercourse 10% of previous weight | |

| |Absence of Menarche after puberty | |

| |Throat ulcers | |

| |Teeth erosion and sensitivity | |

|OBESITY |Family History |Anticipatory guidance on health risk associated |

| |Diabetes |with obesity, diet and exercise program |

| |African-Americans, Hispanics, Native Americans, Pacific Islanders |Refer for medical nutrition therapy |

| |Low Socio-economic Status |Refer for medical/dental evaluation for acute or |

| |Poor Dietary Habits |chronic conditions |

| |High fat, sugar, salt content | |

| |Sedentary Lifestyle | |

| |Physical Indicators: (birth – 10 years) | |

| |>90% weight for height | |

| |Higher percentile than earlier | |

| |Measurements or major change in percentiles | |

| |High non-fasting cholesterol >200 (11–20 years) | |

| |< Tanner Stage 2 | |

| |> 90% weight for height | |

| |> Tanner Stage 2 | |

| |> 20% over desired weight for height | |

PEDIATRIC PREVENTIVE HEALTH GUIDELINES

(continued)

PEDIATRIC PREVENTIVE HEALTH GUIDELINES

(continued)

|CONDITION |RISK FACTORS |MANAGEMENT/COUNSELING |

|PUBERTAL DEVELOPMENT |Assess Tanner Stage |Age appropriate anticipatory guidance Tanner |

| |Female Sexual Development: |Growth and development stage, risk behavior |

| |(As early as 8 years of age in some females) |Instruction in self breast exam and self |

| |Physical Indicators: |testicular exam |

| |Breast bud formation |Refer for medical/dental evaluation if development|

| |Pubic hair growth |grossly accelerated or delayed |

| |Height spurt, increase body fat, and hips widen | |

| |Physical Indicators: (Females 11–20 years) | |

| |Breast Mass | |

| |Delayed Puberty | |

| |Amenorrhea (Primary or Secondary) | |

| |Excessive Bleeding gums | |

| |Male Sexual Development: | |

| |(As early as 10 years of age in some males) | |

| |Physical Indicators: | |

| |Increase in size hands/feet, height, fat and muscle added | |

| |Testes larger, scrotal skin darkens | |

| |Pubic hair sparse base of penis | |

| |Physical Indicators: (Males 11–20 years) | |

| |Inguinal Hernia | |

| |Undescended Testicle | |

| |Delayed Puberty | |

|SUBSTANCE ABUSE |Family History or Personal Use |Anticipatory guidance tobacco, alcohol, drug |

| |Tobacco/Smokeless Tobacco |health risk and facts |

| |Alcohol |Basic nutrition counseling |

| |Drugs (prescription or street) |Refer for medical/dental evaluation, as indicated |

| |Inhalants |Refer for mental health services |

| |Anabolic Steroids | |

| |Physical Indicators, including, but not limited to: | |

| |Restlessness | |

| |Disoriented, slurred speech | |

| |Agitated/aggressive behaviors | |

| |Nodding off | |

| |Persistent nasal drip | |

| |Dilated pupils | |

| |Needle tracks/scars | |

| |Abdominal Distention, firm liver | |

| |Oral pre-cancerous lesions on lips, tongue, or mucosa. | |

| |Periodontal disease and/or numerous caries | |

PEDIATRIC PREVENTIVE HEALTH GUIDELINES

(continued)

|CONDITION |RISK FACTORS |MANAGEMENT/COUSELING |

|SEXUAL ACTIVITY |(Female and Male) |Anticipatory guidance in abstinence, pregnancy |

| |High-Risk Sexual Activity Behavior |prevention, STDs, and HIV |

| |Non-condom use |Laboratory testing for STDs |

| |Non-contraceptive use |Refer to family planning, preconceptional, |

| |Multiple Sexual Partners |prenatal, WIC, and mental health services |

| |Injecting drug user |Refer for medical/dental evaluation if condition |

| |Desire for Pregnancy |indicates |

| |Physical Indicators: |Report sexual abuse to Department for Social |

| |STD |Services or Kentucky State Police KRS 620.030 |

| |Positive pregnancy screening | |

| |Evidence of sexual activity under age 16 | |

| |Oral Human Papilloma Virus, oral lesions | |

|SUDDEN INFANT DEATH SYNDROME |(Birth to 12 months only) |Anticipatory guidance on positioning and bedding, |

|(SIDS) |Increased Risk: |effects of tobacco smoke, and clothing |

| |Prematurity |Offer Grief Counseling if SIDS occurs |

| |Multiples |Refer to local support group if requested |

| |Male Infants | |

| |African-Americans | |

| |Younger Moms | |

| |Positioning (stomach/prone) | |

| |Bedding (soft) | |

| |Overheating | |

| |Tobacco Smoke | |

PEDIATRIC PREVENTIVE HEALTH GUIDELINES

(continued)

|CONDITION |RISK FACTORS |MANAGEMENT/COUNSELING |

|PSYCHOSOCIAL |Family history of mental illness |Assess adult support systems |

| |Inadequate parent/child interaction |Anticipatory guidance stress management |

| |Overly sensitive, irritable |Offer grief counseling in bereavement circumstances |

| |Inexperience, ignorance |Encourage for medical/dental evaluation acute or chronic |

| |Immaturity |conditions |

| |Denial of problems |Refer mental health services and local support groups |

| |Low motivation | |

| |Peer culture, alternative lifestyle | |

| |Rebellion, risk-taking | |

| |Abnormal bereavement | |

| |Sleep disturbance | |

| |Depression | |

| |Suicidal ideation, threats, attempts | |

| |Organic disease | |

| |Physical indicators: | |

| |Unkempt appearance | |

| |Poor hygiene | |

| |Non-congruent verbalization, mannerism, and expressions | |

| |Aggressive behavior, acting out | |

| |Hyperactivity | |

| |Withdrawn | |

| |Failure to interact | |

| |Flat affect | |

| |Low self-esteem | |

| |Self mutilation | |

| |Slash scars wrist/arms | |

|SEDENTARY LIFE |Inactivity |Assist with development of safe/regular exercise routine, |

| |Obesity |counseling specific to physical activity for at least 30 |

| |Physical Handicap |minutes 5 or more times a week |

| | |Basic nutrition counseling |

| | |Encourage for medical/dental evaluation acute and chronic |

| | |conditions |

|INJURIES |Safety Seat/Seat Belt Use (all ages) |Assess working smoke detector in all homes |

| |Fire (All ages, especially ................
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